new ways of managing prostate cancer jahangeer m.malik consultant clinical oncology 7 th november...
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New Ways of Managing Prostate Cancer
Jahangeer M.MalikConsultant Clinical Oncology
7th November 2013
A)Radical RadiotherapyProstate external beam radiotherapy (EBRT)LDR seed brachytherapyHDR brachytherapy boostB)Palliative prostate radiotherapyStrontium-89Radium-223
Risk profilesPROGNOSTIC CATEGORIES
PROGNOSTIC FEATURES
5 YEAR PSA RELAPSE FREE SURVIVAL
GOOD PROGNOSIS T1-2a AND PSA ≤10 ANDGLEASON SCORE ≤6
85%
INTERMEDIATE PROGNOSIS
ONE OF THE PROGNOSTIC INDICATORS RAISED
65%
POOR PROGNOSIS TWO OF THE PROGNOSTIC INDICATORS RAISED
35%
EBRTAdvantages• Suitable for most pts
• Including locally advanced disease T3 and nodal disease
• Don’t need GA
• Acute and late bowel and bladder toxicities
Disadvantages• Prolonged course of Rx 37#
over 7.5 weeks or 19# over 4 weeks
• Doesn’t help obstructive symptoms (may need TURP first)
• PSA follow up
Conformal radiotherapy plan
Sacrum
Rectum
Collimator leaves positioned to shape of target inserted into beam
Open (conventional)rectangular field
Pubis
Target (prostate + margin)
CRT vs IMRT
Beam profile #1
Beam profile #2 Beam
profile #3
Dose intensity
PTV
RO
PTV
RO
3-field RT 3-field IMRT
Prescribed dose (typical distribution)
With IMRT, dose distribution can be shaped to the target to spare organs at risk
Intensity-modulated radiotherapy
RO: risk organPTV: planning target volume
IMRT/hypofractionation
• CHHIP study• 57Gy/19f vs 60Gy/20f vs 74Gy/37f• Conformal IMRT• Toxicity reported at median follow up for
50.5m• Await for bPFS and OS outcome
David Dearnaley et al Lancet Oncol 2012; 13: 43–54
CHHiP ……Acute Toxicity
RTOG 18W
74Gy(N=129)
57Gy(N=129)
60Gy(N=132)
GI≥2 3 (2.3%) 1 (0.8%) 3 (2.3%)
GU≥2 9(7%) 9 (7%) 10 (7.6%)
David Dearnaley et al Lancet Oncol 2012; 13: 43–54
CHHiP ……Late ToxicityBowel Bladder
RTOG 2Y 74Gy(N=138)
57Gy(N=143)
60Gy(N=137)
UK STANDARD
GI≥2 6 (4.3%) 2 (1.4%) 5 (3.6%) 20%
GU≥2 3(2.2%) 0(0%) 3 (2.2%) 8%
RT01 study (64Gy/32f vs 74Gy/37f) RTOG≥2 GU=8% and GI=20% at 2y
Progress at ECC
• Currently treating 80% patients/week with VMAT-IMRT.
• Plan to treat all with IMRT in 6months time.• Plan to treat prostate and pelvis with IMRT for
high risk patients in next 2 years time.
Brachytherapy the ultimate dose escalated IMRT
Permanent LDR Iodine 125 seeds
Temporary Iridium 192 HDR implant
D-LDR brachytherapy
Criteria
•T1-T2b
•Vol<70cc
•No TURP
•Flow >10ml/sec,RV<150ml
•GS6+PSA≤20 or Gs7+PSA≤15 or GS9-10 and PSA≤10
Advantages of Intraoperative
D90 = dose to 90% of the prostate
Correlates with PSA RFS
Day case single visit
Can adjust plan on the day and calculate dose
D100 = 145Gy- 100% 3mm
D150 = 217Gy- 60-70% PTV
D60 = 100Gy = 2cc rectum
Safely boost biopsy +ve sites
Helps avoid excess dose to critical areas
ADVANTAGES• Very high radiation dose 145Gy to
prostate• <1% risk of incontinence• 70% potency rates
DISADVANTAGES/Side effects
• Main side effect - urethritis up to 9-12 months
• Proctitis 5% & Stricture 5-10%
• PSA falls slowly & can bounce causing anxiety for patients
Long term outcome data
Blasko 347 pts 15 yr PFS 86%
Potters 1449 pts 12 yr PFS 89%
Stock & Stone
1561 pts 10 yr PFS 96%
Leeds 1141pts 10 yr PFS 95%
Progress at ECC
Treated 500 patients over last 7 years
Catheterization rate<5%
LR outcome=95% PSA control rate,
IR=85% and HR(GS8/PSA>20)=75%
(CHRISTIE DATA)
Final decision All Patients Localised
Radical Radiotherapy 55 46
AM/AS/WW 54 54
Brachytherapy 32 32
Prostatectomy 52 52
Palliative Radiotherapy NR NR
Hormone therapy 54 11
Other 1 1
Total 248 196
Patients Diagnosed in 2011 who had an oncology consultation and treatment chosen
All Patients Localised
Radical Radiotherapy 97 30
AM/AS/WW 40 38
Brachytherapy 31 28
Prostatectomy 28 25
Palliative Radiotherapy 21 0
Hormone therapy 10 1
Other 7 1
Total 234 123
2012
Usual indication for HDR is a boost
• Where there is a significant predictive risk of extra capsular or seminal vesicle involvement:
External beam
Brachytherapy
•Very high dose per fraction
•Single 15Gy
•Reduced irradiated volume
•Shortened number of XRT visits (15fractions rather 37)
DisadvantagesInpatient treatment
Catheter discomfort
Relatively medically labour intensive
Advantages of HDR
UK Standard
ChristieMartinez
EBRT
Dose (Gy) 74 37.5 46
Number of Fractions 37 15 23
HDR
Dose (Gy) 15 23
Number of Fractions 1 2
2 Gy Equivalence 74 113.6 131.4
HDR----Best Dose-escalation
HDR is the future?
•Combine with functional imaging to boost, alter RT
•ECC will start HDR prostate from next year
4)Strontium-89
• Bone seeking beta rays emitter(electron)• Single IV for bone pains• Maximum range in tissues=8mm• RR=80%• Time to response=7-20days• Duration of response=2months• Toxicity=pain flare, bone marrow suppression
EurJ Cancer, Vol. 27, No. 8, pp. 954-958, 1991
Phase 3 trial closed early due to significant survival benefit in favour of Ra 223 reported at ECCO Stockholm sep 2011
46 vs 65w
P=0.017
ECCO 2011 P3 Interim analysis(ALSYMPCA)
• 922 cases with CRPC and bone mets• 2:1 randomisation with placebo.• 4weekly×6• OS 14 m vs 11.2m (P=0.022, HR 0.69)• Well tolerated ( G3-4 neutropenia 1.8% vs
0.8%)
PROSTATE CANCER TRIALS FOR MORE ADVANCED DISEASE
CRPC
3rd Line estrogense.g.
Diethylstiboestrol
2nd line AAe.g. Bicalutamide
1st line LHRHae.g. Zoladex
DOCETAXELChemotherapy
Trials
Low dose SteroidsDexamethasone Or Prednisolone
New reported trials
After Docetaxel in CRPC
DOCETAXEL
After DOCETAXEL
PROSTATE CANCER TRIALS FOR MORE ADVANCED DISEASE
CRPC
RR=85%,Median duration of response=18-24m
3rd Line estrogense.g.
Diethylstiboestrol
2nd line AAe.g. Bicalutamide
1st line LHRHae.g. Zoladex
DOCETAXELChemotherapy
Trials
Low dose SteroidsDexamethasone Or Prednisolone New reported
trialsAfter Docetaxel
in CRPC
RR=30-40%Median duration of response=3-6m
RR=30%Median duration of response=3-6m
Dex 0.5mg OD,RR 50%,MDR=7mPred 10mgOD,RR30%,MDR=2-3m
Abiraterone
Newer Drugs
2) Abiraterone (Hormone therapy)
3)Denosumab
(Bone)
Enzalutamide
(Hormone therapy)
5) Sipuleucel-T
(Vaccine)
1) Cabazitaxel
(ChemoTherapy)
1)Cabazitaxel
• Tried in patients after Docetaxel.• Diarrhoea, Neutropenia and sepsis.• Survival benefit=2.4m• Available in England• Rejected by SMC
2)Abiraterone
AA 797 736 657 520 282 68 2 0Placebo 398 355 306 210 105 30 3 0
21
HR = 0.646 (0.54-0.77) p < 0.0001
Placebo 10.9 months (95% CI: 10.2-12.0)
AA 14.8 months (95% CI: 14.1-15.4)
100
80
60
40
20
Sur
viva
l (%
)
00 3 6 9 12 15 18
Time to Death (Months)
de Bono et al. Ann Oncol 2010; 21 (10 suppl 8): Abstract LBA5 (oral presentation)Scher et al. J Clin Oncol 2011; 25 (suppl 7): Abstract 4 (oral presentation)
3)Denosumab
Adapted from Roodman D. N Engl J Med. 2004;350:1655.
PTHrP, BMP,TGF-β, IGF, FGF,VEGF, ET1, WNT
Osteoblasts
Inactivate Osteoclast
PDGF, BMPsTGF-β, IGFs
FGFs
Tumor Cell
CA+2
RANKL
RANK
Denosumab
Bone Resorption Inhibited
RANK ligand (RANKL) key mediator for osteoclast formation, function, survival
Potential target for treating bone metastasis
4)Sipuleucel-T (Vaccine)
Immature monocytes thought to mature to fully competent antigen presenting cells (APC), presenting PAP peptides in the patient activates CD4+ and CD8+ T cells
Drake et al. Nature Immunol Rev 2010; 10(8): 580-593
5)Enzalutamide
• Oral hormone tablet• Trial in post-docetaxel chemo patients• 4.8m survival benefit• Awaiting SMC approval, likely to be approved.
After DOCETAXEL
PROSTATE CANCER TRIALS FOR MORE ADVANCED DISEASE
CRPC
RR=85%,Median duration of response=18-24m
3rd Line estrogense.g.
Diethylstiboestrol
2nd line AAe.g. Bicalutamide
1st line LHRHae.g. Zoladex
DOCETAXELChemotherapy
Trials
Low dose SteroidsDexamethasone Or Prednisolone New reported
trialsAfter Docetaxel
in CRPC
RR=30-40%Median duration of response=3-6m
RR=30%Median duration of response=3-6m
Dex 0.5mg OD,RR 50%,MDR=7mPred 10mgOD,RR30%,MDR=2-3m
Abiraterone
12m+